Why Does the Predominant Treatment Paradigm for Borderline Personality Disorder Neglect Family Dynamics?

Marsha Linehan is the creator of what is currently the most prominent psychotherapy paradigm used to treat Borderline Personality Disorder (BPD). Her "Dialectical Behavior Therapy" (DBT) is often said to be the most "empirically-validated" of all such psychotherapy treatments. Actually, as I pointed out previously, DBT is only "empirically validated" mostly for the treatment of one symptom of BPD called parasuicidality. But I digress.

Dr. Linehan's theory of the cause of BPD, for which she cited no actual scientific evidence when she first described it (although there has been some since), is called the "biosocial model."  BPD, she believes, is created by the patient's genetic tendency toward being highly emotionally reactive and slow to recover from an emotionally "dysregulated" state, combined with what she refers to as an invalidating environment.

Invalidation, as used in psychology, is not merely people disagreeing with something that another person said. It is, as I said previously, a process in which individuals communicate to another that the opinions and emotions of the target are invalid, irrational, selfish, uncaring, stupid, most likely insane, and wrong, wrong, wrong. Invalidators let it be known directly or indirectly that their target’s views and feelings do not count for anything to anybody at any time or in any way. In some families, the invalidation becomes extreme, leading to physical abuse and even murder. However, invalidation can also be accomplished by verbal manipulations that invalidate in ways both subtle and confusing.

Bonus question: Do DBT therapists validate parking?

Dr. Linehan wrote only briefly in her book (Cognitive-Behavioral Treatment of Borderline Personality Disorder) about which environment she is talking about as being invalidating (page 56-59), and she barely mentions it in her talks and videos.  It is the family environment in which the person grew up.  Really, what else could it be?  Of course, your spouse and friends can also invalidate you, but why would you choose to fall in with an unpleasant group like that if you were not already accustomed to this sort of treatment? 

When it comes to DBT, however, most of the energy in the treatment described by Dr. Linehan is directed at helping the patients accept themselves as they are, without much said about how they got that way in the first place, combined with other techniques for reducing emotional reactivity. 

At some point in her treatment as described in her book she does say that she focuses on the patient's interpersonal skills later in the therapy process.  She even mentions that family therapy might be included.  Mentions it once or twice.  The first time on page 420.   She does not say anything about what that therapy might entail.

If an invalidating environment is one of two main causes of the disorder as she theorizes, how come she does not address this very much in her treatment plan?

Now comes a story in the New York Times (http://www.nytimes.com/2011/06/23/health/23lives.html?_r=2&pagewanted=all) which may shed light on this question.  Dr. Linehan admits that when she was younger, she "attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on." She added, “I felt totally empty, like the Tin Man."  Self injurious behavior and feeling empty are two of the hallmark symptoms of BPD.  Did she have the disorder?  According to the article at least, BPD is a diagnosis "that she would have given her young self."

I have only met Dr. Linehan once very briefly, and she was perfectly appropriate and personable.  However, I had heard the occasional rumor from other researchers that she has a little bit of the BPD in her.

So why has she so studiously avoided family dynamics in her treatment paradigm when an "invalidating environment" is fully half of her theory about the cause of borderline personality disorder?   And why would she include an invalidating environment in her theory if she, as someone who has struggled with the disorder, had not been invalidated herself?  If her theory is true, she of all people would have experienced that.

The Times article does describe her family a bit, but there does not seem to be a whole lot of dysfunction in the description:

          "Her childhood, in Tulsa, Okla., provided few clues. An excellent student from early on, a natural on the piano, she was the third of six children of an oilman and his wife, an outgoing woman who juggled child care with the Junior League and Tulsa social events. People who knew the Linehans at that time remember that their precocious third child was often in trouble at home, and Dr. Linehan recalls feeling deeply inadequate compared with her attractive and accomplished siblings. But whatever currents of distress ran under the surface, no one took much notice until she was bedridden with headaches in her senior year of high school.  Her younger sister, Aline Haynes, said: “This was Tulsa in the 1960s, and I don’t think my parents had any idea what to do with Marsha. No one really knew what mental illness was.”

Sounds like she was just mentally ill, and that that is the whole explanation for her behavior, does it not?  Just a somehow messed up brain.  But that would only be half of her DBT theory, and a problematic part of the theory at that. 

In one study by researcher extraordinaire Andrew Chanen and others, adolescents who presented for the very first time with BPD did not show the hippocampal and amygdala (parts of the brain's limbic system) volume reductions previously observed in many adult BPD samples - two of the MRI findings of adult BPD considered to be the most significant. They did, however, show small changes in one other part of the brain compared to controls.  (Psychiatry Research: Neuroimaging 163 [2008] 116–125).

This finding could mean that some of the brain phenomena that may create high emotional reactivity come primarily as the effect of some other factor or factors.  An effect, not a first cause. What factors might they be?  An environmental factor?  I would suspect so.  Perhaps the invalidating environment?

So, again, why does Dr. Linehan relegate changing family behavior to what is basically a footnote in her treatment text?  Of course I have no way of knowing. 

With my patients who do not want to look too closely at their family dynamics, however, the reason why is crystal clear.  They are very protective of their families, even if they complain unceasingly about them.  They really do not want anyone to think badly of their family, so they tend to keep the skeletons in the family closet to themselves, at least at first.

Maybe if you just ignore a problem, it will go away.  Not.